Fear, frustration, discomfort… These are a few things you may feel after a knee surgery.
If you have ever undergone an anterior cruciate ligament (ACL) surgery, you know the lengthy rehabilitation that is required for a successful recovery. For some people, a full recovery can take up to one year![ 1] Not only will this require a positive mindset to remain committed to recovery, but there are several other factors that influence your ability to complete all of the necessary rehabilitation. Full commitment to doing all of your exercises after surgery for 6-12 months can be challenging.
This challenge often leads to people not doing everything they need to do, which is called low rehabilitation compliance, some of which you may relate to. After each of the barriers I discuss below I have included "physical therapy advice" from our physical therapist Nirtal Shah who has helped patients overcome these barriers after ACL surgery for the past 17 years. Hopefully, the process of recognizing these barriers, realizing that you are not alone in your challenges and being provided with some helpful tips will allow you to successfully rehabilitate your knee!
The number one reason why people don’t return to their sport after ACL reconstruction is because of fear![ 2] Most people fear re-injury and because of this they are hesitant to return to their usual sport, physical activity, or exercise. In fact, only one third (about 33%) of people return to their previous levels of activity after ACL surgery.[ 2] Some people delay their progress and limit their long term knee function by simply not doing any exercises due to this fear.[ 3] The likelihood of actually sustaining another injury is very low when rehabilitation programs are effective and done consistently.[ 4] Knowing this, you are limiting your progress by not attending your appointments or by avoiding your exercises, both of which are crucial for regaining functional strength in your knee!
Physical therapy advice - Recognize that fear is normal after surgery. Even if you have decided you will never return to a sport it is still important to do all of the rehabilitation that involves jogging, running, cutting, changing directions, etc at the appropriate stage. Meaning you would not do these things in the first month but when you are ready and your physical therapist determines your knee is ready for these activities. Once you have done these movements and also sport specific movements you can decide if you and your knee feel ready to return to sports. I never force my patients to return to sports but I do strongly encourage them to return to their prior level of physical activity and exercise. The health consequences of never returning to physical activity are far worse than re-injuring your ACL. My biggest concern for my patients who are fearful is that they do not regain the full function of their knee. This is a serious problem and leads to more knee joint issues in the future. I also do not deny that there is risk associated with sports. We have a blog on the risk of ACL injuries with various sports which can be found here. In the end it is a personal decision that the patient makes to return to sports. I try to help by providing information and an objective opinion on the health of their knee. In addition our ACL app can also help by overcome this fear by guiding you through your rehabilitation.
If you have ever gone through any type of surgical procedure, you have experienced the physical pain that comes with recovery. One of the reasons people don’t do the things they need to do to recover is because they are in pain. For most, being in pain is a negative experience and often leads to avoidance behaviours such as skipping appointments or not doing their exercises at home. In fact, patients report worsening pain during exercise as a barrier to rehabilitation compliance.[ 5] They believe that exercises causing pain to their area of injury is harmful. As a result, patients will stop performing an exercise if they feel it is painful.[ 5] However, exercise has actually been shown to reduce pain![ 6]
Physical therapy advice - You will definitely have pain after surgery. In the early days after surgery it is very important that you take the pain medication prescribed to you in the correct doses. I have personally had a surgery and lived with the pain first hand and this guides how I help my patients with their pain. You can read about my pain experience and what to expect immediately after surgery here. Besides medication there are other things that help with pain such as ice, compression, elevation, (find a blog about how to do this here)and most importantly movement of the joint in the motions that you are allowed. This means you should move your knee as much as you can and have been instructed by your physical therapist and this will help with your pain. Even in the later stages of recovery often just sitting on a stationary bike (or lying on your back if you do not have access to a bike) and getting your knee to move without resistance (5 minutes of continuous movement) can help with knee pain. Movement is your friend, use it! Many of the exercises in the first month hurt. This is unfortunate but it has to be done. The pain is going to be temporary but the functional gains you make in your knee are going to be long term. There are many ways to help you manage your pain after ACL surgery which you can find in our ACL app.
[ 1]: Chan, D. K., Lonsdale, C., Ho, P. Y., Yung, P. S., & Chan, K. M. (2009). Patient motivation and adherence to postsurgery rehabilitation exercise recommendations: the influence of physiotherapists' autonomy-supportive behaviors. Archives of physical medicine and rehabilitation, 90(12), 1977-1982.
[ 2]: Gignac, M. A., Cao, X., Ramanathan, S., White, L. M., Hurtig, M., Kunz, M., & Marks, P. H. (2015). Perceived personal importance of exercise and fears of re-injury: a longitudinal study of psychological factors related to activity after anterior cruciate ligament reconstruction. BMC sports science, medicine and rehabilitation, 7(1), 4.
[ 4]: Barber-Westin, S. D., Noyes, F. R., & Andrews, M. (1997). A rigorous comparison between the sexes of results and complications after anterior cruciate ligament reconstruction. The American journal of sports medicine, 25(4), 514-526.
[ 5]: Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual therapy, 15(3), 220-228.\n\n[ 6]: Naugle, K. M., Fillingim, R. B., & Riley, J. L. (2012). A meta-analytic review of the hypoalgesic effects of exercise. The Journal of pain, 13(12), 1139-1150.